How To Monitor and Stabilize Depression in Teens and Children
Each time I write a prescription, I have a certain amount of trepidation. Although I know that medications can help, I am also aware of their limitations. It is also important to be vigilant as to whether there are other key factors that are causing a teenager to be overwhelmed (i.e., trauma, substance abuse). However, when children and adolescents are having difficulty functioning because of how impaired they are, medication can be critical. If a teenager is so depressed that she is thinking of tying a phone cord around her neck or jumping out a window, or if she finds it impossible to find the energy to get out of bed, or can’t concentrate long enough to read one page and her grades are dropping, an antidepressant along with therapeutic support can be vital.
Medication may require trial and error. Each time a patient agrees to a “trial” it’s very heroic because often he has already experienced his difficulties as a sign of failure, and if he doesn’t “respond” to a medication he can take it as further confirmation that his life is hopeless. Sometimes, if there is truly a biologic component to the depression, the change can be impressive after four to six weeks. Yet ironically, a positive outcome can be unsettling to a teenager who has come to see himself as permanently disgruntled and irritable. In addition, the wait time involved for most medications to begin to work can seem interminable, particularly because when people are depressed they may have a hard time remembering when they didn’t feel that way. When they start to improve, their mood can brighten, life can feel more manageable and they are less exhausted.
Even when there is improvement, I always invite teenagers to share the understandable ambivalence they may feel about taking medication. Sometimes a child may resent that her parents suggested medication because it implies that she needs to be “fixed.” Or, a teenager may identify with being miserable and become unsettled that medication is changing her core sense of who she is. Other times, particularly in kids who have grown up with a sense that their parents abandoned them, improvement can lead to a fear of dependence on a pill or a clinician. And if a parent has mental illness, a teen may fear that taking medication may make her more like her parents.
The toughest decision is regarding a trial of an antidepressant for a patient who is suicidal. Whereas in a small percentage of patients the antidepressant can make them more agitated and increase suicidal ideation, the medication can also alleviate incessant thoughts and planning about suicide. This is high stakes, so it’s key to share the responsibility with the parents and the teenager. The child needs to tell her parents or doctor if the medication is making her feel worse, and there must be a plan of how to access the doctor quickly and to monitor if there are troubling signs of worsening agitation, depression, or sleep.
A patient whose life has improved with medication will often feel so well that he forgets how bad he used to feel, and stops taking it. I anticipate this and ask that patients be open with me about this. I am working with a patient to see if medication will be helpful but it is always ultimately the patient’s choice. If he decides to transition off of medication, it is important to monitor him and to discuss how we will identify if he is having trouble again. I always encourage the patient to understand about why things reached a crisis, what may need to improve about how he manages stress, family dynamics and his sense of hope and belief in his future.
When I make a recommendation for a trial of medication, I do so as if the child were my own child. Parents should expect the psychiatrist to care deeply about the family, to be transparent about what he knows and doesn’t know and to share how he is making the decision.
Once teenagers who have come to me for help have stabilized, and adequate medication and therapeutic support are in place, it is not uncommon to see them come sauntering into my office, back on track, catching me up with what is going on in their lives — concerts, friends, classes. To me, it is always a blessed miracle that the suicidal feelings, bleak sense of hopelessness and depression was a temporary detour, the crisis was averted and the family left intact.